orthoprep.uk

Prof Ortho

AI-Powered FRCS Ortho Assistant

orthoprep.uk
BOAST Guidelines
BOA / BOFAS Guidance
Foot and Ankle

Operational Delivery of the Multi-Disciplinary Care of the Diabetic Foot

Sets out the service specification and clinical standards for emergency triage, multi-disciplinary team assessment, and urgent surgical intervention for diabetic foot problems.

Key standards

  • ›Immediate emergency admission for limb- or life-threatening infections, wet gangrene, ascending cellulitis, or deep space abscess.
  • ›Non-emergency active diabetic foot disease must be reviewed by the Multidisciplinary Foot Service (MDFS) within one working day.
  • ›Probe-to-bone test should be performed on all open diabetic ulcers to assess for underlying osteomyelitis.
  • ›Baseline plain radiography for every new active diabetic foot problem to rule out gas, foreign bodies, and osteomyelitis.
  • ›Collect deep tissue specimens or bone biopsies for microbiology; avoid superficial ulcer swabs.
  • ›Urgent surgical debridement and drainage for necrotising soft tissue infections or closed compartment sepsis.
  • ›Urgent vascular surgery assessment and revascularisation pathway for ischaemic, non-healing, or gangrenous lesions.
  • ›Immediate mechanical offloading (e.g. total contact casting or cast walker) for active plantarly located wounds and acute Charcot events.

Introduction

Active diabetic foot problems present significant risks of morbidity, limb loss, and mortality. Rapid triage and coordinated specialist input are mandatory to preserve limb and life.

Standards

  • Immediate Emergency Referral: Diabetic patients presenting with suspected limb- or life-threatening infections, systemic sepsis, wet gangrene, ascending cellulitis, or compartment syndrome must be referred immediately to the emergency department or on-call acute surgical team.
  • Non-Emergency Active Foot Problems: Active ulceration without systemic sepsis, new onset Charcot neuroarthropathy, or suspected deep tissue infection must be assessed by a dedicated Multidisciplinary Foot Service (MDFS) or Foot Protection Service within one working day.
  • Multidisciplinary Team Structure: Dedicated diabetic foot pathways require rapid access to orthopaedic/foot and ankle surgery, vascular surgery, diabetology/endocrinology, specialist podiatry, infectious diseases/microbiology, and tissue viability nursing.

Investigation and Assessment

  • Full clinical examination documenting limb perfusion (palpable pulses, handheld Doppler, ankle-brachial pressure indices), neurological status (10g monofilament test), and detailed wound inspection including size, depth, and probe-to-bone test.
  • Baseline plain radiographs of the foot and ankle to evaluate osteolysis, cortical breach, foreign bodies, gas in soft tissues, and Charcot-related joint subluxation or fracture.
  • Urgent inflammatory markers (WBC, CRP, ESR) and metabolic monitoring (blood glucose, HbA1c, renal profile, venous blood gas / lactate).
  • Deep microbiological tissue sampling (curettage or deep intraoperative biopsy) rather than superficial skin swabs prior to or at time of debridement.

Management and Timing

  • Emergency Surgery: Patients with gas gangrene, necrotising soft tissue infection, or deep abscess must undergo prompt surgical decompression, wide debridement of necrotic non-viable tissue, and source control without delay.
  • Vascular Optimization: Rapid vascular assessment and revascularisation (endovascular or surgical bypass) should be performed urgently in critical limb-threatening ischaemia to optimize perfusion prior to or alongside wound reconstruction.
  • Empirical Antimicrobial Therapy: Prompt initiation of broad-spectrum intravenous antibiotics targeting Gram-positive, Gram-negative, and anaerobic organisms according to local antimicrobial guidelines, subsequently rationalised on deep culture results.
  • Offloading and Immobilisation: Immediate pressure relief and mechanical offloading (e.g. non-weight-bearing total contact casting or rigid removable boot) for ulcerations and suspected acute Charcot neuroarthropathy.

Documentation and Governance

  • Standardised clinical documentation outlining wound stage, depth, ischaemia, and presence of infection (e.g. SINBAD or IWGDF/IDSA classification systems).
  • Regular clinical audit of local major and minor lower extremity amputation rates, 30-day readmissions, and multidisciplinary referral compliance.

Exam-tested points

  • ›A positive probe-to-bone (PTB) test in a high-prevalence setting has a high positive predictive value for underlying osteomyelitis and warrants radiographic and advanced imaging correlation.
  • ›Differentiating acute Charcot neuroarthropathy from infection: Charcot presents with an erythematous, warm, swollen foot, often without an open skin break; elevation of the limb for 5–10 minutes typically diminishes Charcot erythema, whereas cellulitic erythema persists.
  • ›Superficial wound swabs are contraindicated because they reflect superficial colonisers rather than pathogens responsible for deep tissue infection and osteomyelitis.
  • ›Revascularisation must precede or be integrated into elective reconstructive surgery or minor digital amputations; inadequate arterial flow ensures wound failure.
  • ›The emergency surgical goal is source control and debridement of all non-viable tissue back to bleeding margins while preserving durable weight-bearing plantar surfaces where safe.
  • ›Offloading remains the single most critical intervention for healing neuropathic plantar ulcers; total contact casting (TCC) is the gold standard method.
Official BOA source
Read the official guideline

Test yourself on Foot and Ankle

Practise SBA questions covering this subspecialty.

Practice this topic →